complexity & change in environment, biomedicine & society

Changes in mammogram guidelines: Responding to the personal-story response III

How does the new trolley scenario (see previous post) provide a different angle to approach the incommensurability of the individual experience and the net social benefit? (The need for a new angle arose because allocation of health care funds according to benefit/cost calculations [see earlier post] cannot be expected to satisfy the person with the story about screening saving their life. )

Unlike the original trolley scenario, this one corresponds somewhat to a situation found in the real world and allows us to reframe how people can think ethically about benefit/cost calculations for a population versus the story about screening saving an individual person’s life. I say somewhat because there is no guarantee that the savings if group F took the track B choice would be used to provide the track A choice to group P. Perhaps they would go to more insurance coverage for viagra use! Working to direct savings to group P would be part of the ethical choices and actions this new trolley problem asks of you.

In case the translation isn’t obvious, group P are the poor who don’t get routine screenings at any age and group F are the under fifty year olds, including women under 40 who don’t get routine mammograms and those in the 40-49 year who the USPSTF proposed should no longer get them. The choice you are asked to make in the new trolley scenario is for all women, which includes those in group P who didn’t get routine screening in their 50s or 60s and died from breast cancer, not only those with a screening-based diagnosis in their 40s who lived to write letters against changes to guidelines. The choice is not a matter of someone, such as USPSTF, devaluing the life of the letter writer (or of a 40-49 year old woman who can imagine routine screening allowing her to live to write such a letter), but of someone looking at the option to have such a choice coming at a cost to others. Indeed, taking the choice may devalue the lives of women who do not have a voice in the debate, some of whom may die for lack of routine screening in their 50s and 60s.

You might protest that there need not be such a trade-off—funds should be made available for everyone to have the same basic health choice. However, ethics has to factor in the actual world, not assume some hypothetical or possible future world. Or, at least, that’s the line of thinking that the new trolley scenario aims to draw the reader into.

Now that I’ve invented the new trolley problem, I’m not sure if wouldn’t be better simply to state the ethical problems directly. Perhaps that will be the subject of a future post.